NCLEX NSG 4100
EXAM 1
ADULT HEALTH 2 EXAM
LATEST WITH VERIFIED QUESTIONS AND
ANSWERS GRADED A+
,A client who has been receiving radiation therapy for bladder cancer tells the
nurse that it feels as if she is voiding through the vagina. The nurse interprets that
the client may be experiencing which condition?
1.Rupture of the bladder
2.The development of a vesicovaginal fistula
3.Extreme stress caused by the diagnosis of cancer
4.Altered perineal sensation as a side effect of radiation therapy
- CORRECT ANSWER - 2
Rationale:A vesicovaginal fistula is a genital fistula that occurs between the
bladder and vagina. The fistula is an abnormal opening between these two body
parts and, if this occurs, the client may experience drainage of urine through the
vagina. The client's complaint is not associated with options 1, 3, or 4.
The nurse is teaching a client about the risk factors associated with colorectal
cancer. The nurse determines that further teaching is necessary related to
colorectal cancer if the client identifies which item as an associated risk factor?
1.Age younger than 50 years
2.History of colorectal polyps
,3.Family history of colorectal cancer 4.Chronic inflammatory bowel disease -
CORRECT ANSWER - 1
Rationale:Colorectal cancer risk factors include age older than 50 years, a family
history of the disease, colorectal polyps, and chronic inflammatory bowel disease.
The nurse is assessing the perineal wound in a client who has returned from the
operating room following an abdominal perineal resection and notes
serosanguineous drainage from the wound. Which nursing intervention is most
appropriate?
1.Clamp the surgical drain.
2.Change the dressing as prescribed.
3.Notify the health care provider (HCP). 4.Remove and replace the perineal
packing. - CORRECT ANSWER - 2
Rationale:Immediately after surgery, profuse serosanguineous drainage from the
perineal wound is expected. Therefore, the nurse should change the dressing as
prescribed. A surgical drain should not be clamped because this action will cause
the accumulation of drainage within the tissue. The nurse does not need to notify
the HCP at this time. Drains and packing are removed gradually over a period of 5
to 7 days as prescribed. The nurse should not remove the perineal packing.
, The nurse is reviewing the history of a client with bladder cancer. The nurse
expects to note documentation of which most common sign or symptom of this
type of cancer?
1.Dysuria
2.Hematuria
3.Urgency on urination
4.Frequency of urination - CORRECT ANSWER - 2
Rationale:The most common sign in clients with cancer of the bladder is
hematuria. The client also may experience irritative voiding symptoms such as
frequency, urgency, and dysuria, and these symptoms often are associated with
carcinoma in situ. Dysuria, urgency, and frequency of urination are also symptoms
of a bladder infection.
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis
is being assessed by the nurse. Which assessment findings would be consistent
with acute pancreatitis? Select all that apply.
1.Diarrhea
2.Black, tarry stools
3.Hyperactive bowel sounds
4.Gray-blue color at the flank
EXAM 1
ADULT HEALTH 2 EXAM
LATEST WITH VERIFIED QUESTIONS AND
ANSWERS GRADED A+
,A client who has been receiving radiation therapy for bladder cancer tells the
nurse that it feels as if she is voiding through the vagina. The nurse interprets that
the client may be experiencing which condition?
1.Rupture of the bladder
2.The development of a vesicovaginal fistula
3.Extreme stress caused by the diagnosis of cancer
4.Altered perineal sensation as a side effect of radiation therapy
- CORRECT ANSWER - 2
Rationale:A vesicovaginal fistula is a genital fistula that occurs between the
bladder and vagina. The fistula is an abnormal opening between these two body
parts and, if this occurs, the client may experience drainage of urine through the
vagina. The client's complaint is not associated with options 1, 3, or 4.
The nurse is teaching a client about the risk factors associated with colorectal
cancer. The nurse determines that further teaching is necessary related to
colorectal cancer if the client identifies which item as an associated risk factor?
1.Age younger than 50 years
2.History of colorectal polyps
,3.Family history of colorectal cancer 4.Chronic inflammatory bowel disease -
CORRECT ANSWER - 1
Rationale:Colorectal cancer risk factors include age older than 50 years, a family
history of the disease, colorectal polyps, and chronic inflammatory bowel disease.
The nurse is assessing the perineal wound in a client who has returned from the
operating room following an abdominal perineal resection and notes
serosanguineous drainage from the wound. Which nursing intervention is most
appropriate?
1.Clamp the surgical drain.
2.Change the dressing as prescribed.
3.Notify the health care provider (HCP). 4.Remove and replace the perineal
packing. - CORRECT ANSWER - 2
Rationale:Immediately after surgery, profuse serosanguineous drainage from the
perineal wound is expected. Therefore, the nurse should change the dressing as
prescribed. A surgical drain should not be clamped because this action will cause
the accumulation of drainage within the tissue. The nurse does not need to notify
the HCP at this time. Drains and packing are removed gradually over a period of 5
to 7 days as prescribed. The nurse should not remove the perineal packing.
, The nurse is reviewing the history of a client with bladder cancer. The nurse
expects to note documentation of which most common sign or symptom of this
type of cancer?
1.Dysuria
2.Hematuria
3.Urgency on urination
4.Frequency of urination - CORRECT ANSWER - 2
Rationale:The most common sign in clients with cancer of the bladder is
hematuria. The client also may experience irritative voiding symptoms such as
frequency, urgency, and dysuria, and these symptoms often are associated with
carcinoma in situ. Dysuria, urgency, and frequency of urination are also symptoms
of a bladder infection.
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis
is being assessed by the nurse. Which assessment findings would be consistent
with acute pancreatitis? Select all that apply.
1.Diarrhea
2.Black, tarry stools
3.Hyperactive bowel sounds
4.Gray-blue color at the flank
